"VISA
EXPRESS"
NAME:
SURNAME:
ADDRESS:
CITY:
STATE:
COUNTRY:
POSTAL CODE:
PHONE#:
EMAIL ADDRESS:
ITEM DESCRIPTION:
QUANTITY:
AMOUNT:
VISA CARD#:
EXPIRY DATE:
I THE ABOVE MENTIONED NAME, HEREBY CERTIFY
THE ABOVE INFORMATION IS TRUE AND CORRECT AND
AGREE THAT ALL SALES ARE FINAL AND WITHOUT LIABILITY.